[YSPNetwork] FW: [sclistserve] Who Are We? Coming of Age on Antidepressants

[Effie Malley]

>From the New York Times
April 15, 2008

Mind


Who Are We? Coming of Age on Antidepressants 


By RICHARD A. FRIEDMAN, M.D.

"I've grown up on medication," my patient Julie told me recently. "I
don't have a sense of who I really am without it." 

At 31, she had been on one antidepressant or another nearly continuously
since she was 14. There was little question that she had very serious
depression
<http://health.nytimes.com/health/guides/symptoms/depression/overview.ht
ml?inline=nyt-classifier>  and had survived several suicide attempts
<http://health.nytimes.com/health/guides/disease/suicide-and-suicidal-be
havior/overview.html?inline=nyt-classifier> . In fact, she credited the
medication with saving her life.

But now she was raising an equally fundamental question: how the drugs
might have affected her psychological development and core identity.

It was not an issue I had seriously considered before. Most of my
patients, who are adults, developed their psychiatric problems after
they had a pretty clear idea of who they were as individuals. During
treatment, most of them could tell me whether they were back to their
normal baseline. 

Julie could certainly remember what depression felt like, but she could
not recall feeling well except during her long treatment with
antidepressant medications. And since she had not grown up before
getting depressed, she could not gauge the hypothetical effects of
antidepressants
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto
pics/antidepressants/index.html?inline=nyt-classifier>  on her emotional
and psychological development.

Her experience is far from unique. Since their emergence in the late
1980s, serotonin reuptake inhibitors like Prozac
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto
pics/prozac_drug/index.html?inline=nyt-classifier>  and Zoloft
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto
pics/zoloft_drug/index.html?inline=nyt-classifier>  have become some of
the most widely prescribed drugs in the world, for depressed teenagers
as well as adults. Because depression is often a chronic, recurring
illness, there are certain to be many young people, like Julie, who are
coming of age on these newer antidepressants.

We know a lot about the course of untreated depression, probably more
than we do about very long-term antidepressant use in this population.
We know, for example, that depression in young people is a very serious
problem; suicide
<http://health.nytimes.com/health/guides/disease/suicide-and-suicidal-be
havior/overview.html?inline=nyt-classifier>  is the third-leading cause
of death in adolescents, not to mention the untold suffering and
impaired functioning this disease exacts.

By contrast, the risk of antidepressant treatment is small. A 2004
review by the Food and Drug Administration
<http://topics.nytimes.com/top/reference/timestopics/organizations/f/foo
d_and_drug_administration/index.html?inline=nyt-org> , analyzing
clinical trials of the drugs, did show an elevated risk of suicidal
thinking and nonlethal suicide attempts in young people taking
antidepressants - 3.5 percent, compared with 1.7 percent of those taking
a placebo. But since the lifetime risk of actual suicide in depressed
people ranges from 2.2 to 12 percent, risk from treatment is dwarfed by
the risks of the disease itself.

Still, what do we know about the effects of, say, 15 to 20 years of
antidepressant drug treatment that begins in adolescence
<http://health.nytimes.com/health/guides/specialtopic/puberty-and-adoles
cence/overview.html?inline=nyt-classifier>  or childhood? Not enough.

The reason has to do with the way drugs are tested and approved. To get
F.D.A. approval, a drug has to beat a placebo in two randomized clinical
trials that typically involve a few hundred subjects who are treated for
relatively short periods, usually 4 to 12 weeks. 

So drugs are approved based on short-term studies for what turns out to
be long-term - often lifelong - use in the world of clinical practice.
The longest maintenance study to date of one of the newer
antidepressants, Effexor, lasted only two years and showed the drug to
be superior to a placebo in preventing relapses of depression. 

What do I say to a depressed patient who is doing well after five years
on such a drug but can't stop without a depressive relapse and who wants
reassurance that the drug has no long-term adverse effects?

I usually say that we have no evidence that the drug poses a risk with
long-term use; and since the risk of untreated depression is much
greater than the hypothetical risk of the drug, it makes sense to stay
on it.

This large gap in our clinical knowledge is compounded by the public's
growing and well-founded skepticism about research sponsored by drug
makers. A study in the January 2008 issue of The New England Journal of
Medicine
<http://topics.nytimes.com/top/reference/timestopics/organizations/n/new
_england_journal_of_medicine/index.html?inline=nyt-org> , involving 74
clinical trials with 12 antidepressants, found that 97 percent of
positive studies were published, versus 12 percent of negative studies. 

Clearly, physicians and the public need much better data on the safety
and efficacy of drugs after they hit the market, which at present
consists mainly of anecdotes and case reports.

Congress recently reauthorized the Prescription Drug User Fee Act, which
will expand the F.D.A.'s post-marketing drug surveillance, though I
think it did not go far enough in mandating the use of powerful
epidemiological strategies to monitor drugs over the long term.

Beyond these concerns, there are other important issues to consider in
long-term use of antidepressants, especially in young people. One
patient, a woman in her mid-20s, told me that she felt pressured by her
boyfriend to have sex more often than she wanted. "I've always had a low
sex drive," she said.

For the past eight years she had been taking Zoloft, which like all the
antidepressants in its class is known to lower libido and to interfere
with sexual performance. She had understandably mistaken the side effect
of the drug for her "normal" sexual desire and was shocked when I
explained it: "And I thought it was just me!"

This just underscores how tricky it can be to use psychotropic drugs
during adolescence - when the brain is still developing, when one's
identity is still work in progress. 

The drugs save lives, and we often have no choice but to use them - even
if we have questions about their long-term use. But the questions are
big ones, and we owe it to our patients to try to answer them.

Richard A. Friedman is a professor of psychiatry at Weill Cornell
Medical College.

 

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